Vaccine prevention for existing and emerging viral threats

Vaccine prevention for existing and emerging viral threats Viruses in May Blue Mountains 18 May 2018 www.ncirs.edu.au https://www.apprise.org.au/ Prof Kristine Macartney Director, NCIRS www.ncirs.usyd.edu.au

The old, the new and the emerging The big picture EIDs New vaccines JE Dengue Zika Ebola (Zoster, Flu, HPV if time) Not today. Many others..

Emerging viral diseases from a vaccinology perspective: preparing for the next pandemic Barney S. Graham * and Nancy J. Sullivan* Nature Immunology https://doi.org/10.1038/s41590-017-0007-9

Traditional live-attenuated or whole-inactivated vaccine approaches / classical methods likely not be rapid enough to respond to a pandemic crisis Focus of developing EID vaccines based on newer gene-based antigen-delivery technologies, some of which have not yet been licensed for use humans. Emerging viral diseases from a vaccinology perspective: preparing for the next pandemic Barney S. Graham * and Nancy J. Sullivan* Nature Immunology https://doi.org/10.1038/s41590-017-0007-9

https://youtu.be/jgmw9bczeig

n engl j med 376;7 nejm.org February 16, 2017

http://www.who.int/immunization/research/vaccine_pipeline_tracker_spreadsheet/en/

JE VACCINE PATH/Thet Htoo A young girl in Shan State, Myanmar, proudly displays her freshly inked finger proof she received the Japanese encephalitis vaccine. Immunization campaigns began in November and conclude this week, followed by routine immunization in 2018. PATH provided technical assistance to Myanmar to introduce the vaccine, which reached an estimated 14.5 million children.

JE and vaccines Leading cause of viral encephalitis in Asia ~3 billion people, including 700 million children, at risk An estimated 70,000 clinical cases Up to 20,000 deaths each year, mostly < 15 years 1 in 300 infections results in symptomatic illness. Illness can progress to encephalitis 30% fatality rate 3 JE vaccines prequalified by the WHO: CD-JEV (also known as SA 14-14-2), a live attenuated vaccine (Chengdu Institute of Biological Products, India); JE-CV, a live recombinant JE vaccine (Government Pharmaceutical Organization-Merieuk Biological Products Co., Ltd, Thailand).; and JEEV, an inactivated, Vero cell-derived JE vaccine manufactured by Biological E, India. Australia: live attenuated recombinant JE vaccine (Imojev, Sanofi and inactivated vaccine (JEspect Valneva Scotland Ltd/CSL )

Fig 1. Percent difference in expected and observed incidence of Japanese encephalitis following vaccination campaign, by district, Nepal. Upreti SR, Lindsey NP, Bohara R, Choudhary GR, Shakya S, et al. (2017) Updated estimation of the impact of a Japanese encephalitis immunization program with live, attenuated SA 14-14-2 vaccine in Nepal. PLOS Neglected Tropical Diseases 11(9): e0005866. https://doi.org/10.1371/journal.pntd.0005866 http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0005866

DENGUE VACCINE

Antibody-dependent enhancement (ADE) At a specific concentration, heterotypic antibodies bind but do not neutralize virions of the subsequent infecting DENV type. These virus-immune complexes are recognized by Fcγ receptors that facilitate virus entry and replication in target immune cells. Initiates an immune cascade - results in vascular leak and severe dengue disease

Dengue vaccine CYD-TDV (Dengvaxia,Sanofi Pasteur) Live recombinant tetravalent dengue vaccine 3-dose series on a 0/6/12 month schedule 9-45 years of age living in endemic areas now licensed in 20 countries. Two large Phase 3 trials involving over 30,000 participants aged 2 to 16 years included: VE confirmed dengue, over a 25-months in 9-16 y/o was 65.6% reduced severe dengue by 93% and hosp dengue by 82%. an increased risk of hospitalized dengue was seen in the 2 to 5- y/o in Year 3 of follow-up. Need for more studies identified

Studies used newly developed NS1-based antibody assay applied to blood samples taken 13 months after vaccination to retrospectively infer dengue serostatus at time of first vaccination Dengvaxia Licenced WHO recommend Endemic countries Sanofi New data on risk in seronengative WHO statements Must do screening prior to vaccination Dec 2015 May-July 2016 Nov 2017 Dec April 2018

Dengvaxia New analyses from the long-term safety follow-up: In the first 25 months after the first dose of vaccine. VE confirmed dengue in baseline seropositive participants 9 years of age: 76% (95%CI: 63.9, to 84.0), VE lower in baseline seronegative participants: 38.8% (95%CI: 0.9 to 62.9%) There is an increased risk of hospitalized and severe dengue in seronegative individuals starting about 30 months after the first dose. In areas of 70% dengue seroprevalence, over a 5-year follow-up, for every 4 severe cases prevented in seropositive, there would be one excess severe case in seronegative per 1,000 vaccinees; for every 13 hospitalizations prevented in seropositive vaccinees, there would be 1 excess hospitalization in seronegative vaccinees per 1,000 vaccinees. https://www.thelancet.com/journals/laninf/article/piis1473-3099(17)30752-1/fulltext

http://news.abs-cbn.com/focus/multimedia/slideshow/12/08/17/timeline-the-philippinesdengue-vaccine-program

For countries considering vaccination as part of their dengue control program, a pre-vaccination screening strategy would be the preferred option, in which only dengue-seropositive persons are vaccinated.

ZIKA VACCINE

- at least 2,400 healthy men and non-pregnant women ages 15-35 years. - part A (Houston, Miami and San Juan) - two additional sites in San Juan, two sites in Costa Rica, and one site each in Peru, Brazil, Panama and Mexico.

a small circular piece of DNA called a plasmid into which scientists have inserted genes that encode two proteins found on the surface of the Zika virus. Once injected into muscle, the proteins assemble into particles that mimic the Zika virus and trigger the body s immune system to respond NIAID website Q and A

EBOLA VACCINES

Kaplan-Meier plots for all confirmed cases of Ebola virus disease among all contacts and contacts of contacts in immediate, delayed, and non-randomised clusters

http://apps.who.int/iris/bitstream/handle/10665/272536/sitrep-evd-drc-20180514.pdf?ua=1

Thank you, Questions?

Extra slides

FLU VACCINE

Notifications More testing and more flu: national influenza notifications by month and year 120000 100000 2009 2017 80000 5-year average 60000 40000 20000 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month Source: National Notifiable Diseases Surveillance System

Incidence (per 100,000) ICD-coded hospitalisation for influenza 2002 2013 Highest rates in young children 200 Influenza vaccine not indicated; Vaccinate pregnant women 180 160 Influenza vaccine funded only with risk factors 140 120 100 80 60 Hospitalisation ICU Vaccine funded for all > 65 years 40 20 0 0-5m 6-23m 2-4y 5-11y 12-17y 18-64y 65y Age group

Most flu- hospitalised children previously well. FluCAN PAEDS (sentinel hospitals www.paeds.edu.au) Mortality: 0.3% ICU admission: 8.7% CPAP-Bipap: 28.3% PP Ventilation: 38.1% ECMO: 0.7% Seizures: 10.1% Children aged <16 years

Vaccine as effective in children as in healthy adults 2008, 2010-2013 (unadjusted) 2008-2010-2013 (adjusted) VE: 62.3% (95%CI: -6.6, 86.7) 62% 2014 (unadjusted) 2014 (adjusted) VE: 55.5% (95%CI: 11.6, 77,6) 55% -20% 0% 20% 40% 60% 80% 100% Children aged <16 years Blyth CC et al, Vaccine 2015; Blyth CC et al; Eurosurveillance 2016

2018 influenza vaccines Virus strains included in the 2018 southern hemisphere seasonal influenza vaccines are: A (H1N1): an A/Michigan/45/2015 (H1N1)pdm09 like virus A (H3N2): an A/Singapore/INFIMH-16-0019/2016(H3N2) like virus B: a B/Phuket/3073/2013 like virus B: a B/Brisbane/60/2008 like virus (not included in the TIVs)

HPV VACCINE

New HPV vaccine program changes Gardasil 9 includes HPV types in Gardasil (6, 11, 16 and 18) plus five more oncogenic types (31, 33, 45, 52 and 58) The two doses of Gardasil 9 are recommended at an interval of between 6 to 12 months apart (if started before 15 th birthday) A three-dose schedule only recommended for those starting course at age 15 years and any age who have major immunocompromise